Provider Demographics
NPI:1841336591
Name:PAN, NATHAN CHANG (DDS)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:CHANG
Last Name:PAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2839 YORBA ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-2748
Mailing Address - Country:US
Mailing Address - Phone:415-564-6675
Mailing Address - Fax:
Practice Address - Street 1:585 BEVERLY AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-1929
Practice Address - Country:US
Practice Address - Phone:510-632-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA31508OtherDENTAL LICENSE